Basic Information
| Provider Information | |||||||||
| NPI: | 1861501363 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EARL | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9149 ESTATE THOMAS | ||||||||
| Address2: | SUITE 1074 | ||||||||
| City: | ST THOMAS | ||||||||
| State: | VI | ||||||||
| PostalCode: | 008022615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3407142845 | ||||||||
| FaxNumber: | 6039243993 | ||||||||
| Practice Location | |||||||||
| Address1: | 9149 ESTATE THOMAS PARAGON MEDICAL BUILDING | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | ST. THOMAS | ||||||||
| State: | VI | ||||||||
| PostalCode: | 00802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3407142845 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 09/26/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 0337P | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 30331366 | 05 | NH | MEDICAID |